General Comments

This is not an all-inclusive “cookbook” for every Neurology patient, but a set of
guidelines to help you rationally approach patients with certain syndromes (sets of signs and symptoms which suggest a lesion in particular parts of the nervous system).

As you obtain a history and perform a neurological physical exam,
try initially to localize all the patient’s signs and symptoms to one, single lesion in the nervous system. It may be surprising that a variety of signs and symptoms, at first glance apparently unrelated, on second thought can localize accurately to a single lesion. If this approach fails, then consider multiple, separate lesions for the patient’s signs and symptoms.

The tempo or rate at which signs and symptoms develop or occur often suggests the underlying pathological process.

Toximetabolic disorders, potentially treatable and reversible, may mimic lesions in the nervous system, and can evolve at variable tempos.

Hereditary conditions may be congenital (present at birth) and nonprogressive or static, or develop later in life, with variable rates of progression. Family members affected by the same genetic disorder may be remarkably similar with regards to onset and clinical severity, while some genetic disorders vary widely regarding when and how severely family members are affected.

In the central nervous system, “positive symptoms or phenomena,” such as flashes of light, or a tingling sensation, suggest “excitation” or increased activity in the nervous system: migraine or seizure.
“Negative symptoms or phenomena,” such as blindness or sensorimotor deficits, suggest “inhibition” or decreased activity (or a permanent deficit) in the nervous system: stroke, tumor or degenerative disorder.

More extensive or diffuseareas of sensory impairment favor a lesion of brain, brain stem (hemibody deficit) or spinal cord (truncal level), with the exception of a distal “stocking and glove” deficit typical of polyneuropathy

Patients with visual changes

Blurry vision or diplopiaa.

Is it a problem with refraction (need for eyeglasses)?

If episodic and brief in duration, are there other accompanying symptoms to suggest a problem in the brainstem and cranial nerves, or more rostral?

TIA?

compression or traction on brain stem and cranial nerves?

If the diplopia improves by covering either eye, consider a problem with the extraocular muscles or the cranial nerves innervating them.

If the diplopia improves by covering only one eye, consider a problem with the lens or retina of that eye

Dementia is the progressive loss of cognitive and behavioral function, subacute to chronic in nature, and often irreversible.

Any mental status testing must be interpreted in light of the patient’s educational, socioeconomic and cultural background.

Mild memory deficits occur with normal aging, as “benign forgetfulness.”
Serial examinations over time may be needed to clearly show progression of a deficit.

When developed, dementia involves multiple deficits of memory, orientation, judgement, behavior and learned skills. Predominant deficits of only one type suggest a focal lesion in certain areas of the brain.

Generalized tonic-clonic (convulsive) seizure: often occurs from rapid secondary spread of a partial seizure in adults, whether or not a localizing prodromal aura is detectable; a clinically observable convulsion with loss of consciousness and postictal confusion